Measure Would Cap Insured Out-of-Pocket Cost of Insulin at $35

The U.S. House of Representatives has passed legislation that would cap the out-of-pocket cost of insulin at $35 a month for people with group or private health insurance.

While the measure still has to face a vote in the Senate, it has broad backing after the cost of insulin has skyrocketed in recent years. People who used to pay less than $100 a month for the vital medication are sometimes paying more than $1,000, depending on their health insurance coverage.

More than 37 million Americans have diabetes, and this legislation could be a game-changer for the estimated 7 million who have to take insulin to control their condition.

In the past decade, the cost of insulin has tripled in the United States, with average out-of-pocket costs rising to about $666 a month. But some people need specific brands and can pay more than $1,000 a month for their brand.

For example, David Tridgell, a Minneapolis endocrinologist, wrote an op-ed in The Washington Post citing the costs typical diabetics face:

  • Patients with Type 1 diabetes tend to use two or three vials of insulin per month. At the current cost of one vial of Humalog 50/50, these patients would spend $780 to $1,170 on their insulin every month.
  • Type 2 diabetes patients sometimes need six or more vials a month, which would run up the costs to $2,341 or more every month.

It can be especially costly for individuals enrolled in high-deductible health plans, in which enrollees have to pay the list price for their insulin until their deductible is met. This could mean thousands of dollars out of pocket before the insurer will cover the drug. Because of the soaring costs, many people report reducing dosages or rationing to make their insulin last longer.

Diabetes can lead to other serious health complications, including kidney failure, heart disease and loss of vision.

How it would work

HR 6833 would bar private health insurers, health plans and self-insured employers from applying a deductible on insulin and require that diabetics pay no more than $35 or the amount equal to 25% of the negotiated price of the selected insulin product, whichever is lower.

For no more than $35 a month, the Affordable Insulin Now Act would require private group or individual plans to cover both vial and pen dosage forms and any of the following insulin types:

  • Rapid-acting,
  • Short-acting,
  • Intermediate-acting, and
  • Long-acting.

Medicare Part D plans, Medicare stand-alone drug plans and Medicare Advantage drug plans would be required to charge no more than $35 for whichever insulin products they cover in 2023 and 2024, and for all insulin products beginning in 2025.

HR 6833 passed on a vote of 232 to 193, with 12 Republican representatives voting with the Democrats. The measure has been sent to the Senate.  If it passes the Senate and is signed into law, it will take effect in 2023.

We’ll keep you posted if this bill lands on President Biden’s desk and he signs it.

Recent & Related

PBMs Feeling the Heat on All Fronts

PBMs Feeling the Heat on All Fronts

While drugmakers have been assailed for years for increasing their prices and driving the cost of medications higher and higher, there is another player in the health care space that is receiving increased scrutiny: pharmacy benefit managers. PBMs are intermediaries,...

read more
The Risk Report – May 2023

The Risk Report – May 2023

Download Volume 5, Issue 5 of The Risk Report In this Edition: Insurers Promise to Keep Covering Preventive Services HDHP Plan Satisfaction Lags that of Traditional Plans Getting Benefits of Self-Funding without the Risks Employers Expand Mental Health Benefits...

read more